BP-23731RESIDENTIAL 2002
S, T[ON 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner
�r of Record:
PC- N E�
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Name ((print)
Contact Address Phone Number
2.2 Authorized Agent:
Name (print)
Contact Address PhoneNumber
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
Address
Expiration Date
Signarure Telephone
3.2 Registered Home Improvement Contractor:
Not Applicable ❑
Are you a Home Improvement Contractor subject to (780 CMR-6)? ❑ yes ❑ no
If no go to the next section!
Are you claiming exemption from the requirement? ❑ yes ❑ no
;t
If yes, submit the
required affidavit!
Colnp�any Name
Registration Number (if none, state "none") -
Address
Signature Telephone
Expiration Date
3.3 For Residential Remodel Work Only
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND:
QUESTIONS OR COMPLAINTS call or write:
Home Improvement Contractors Registration, One Ashburton Place- Roost 1301, Boston, b1A 02108, (617) 727-8598
Owners Name (print)
Signature
by signing the above, the home owner acknowledges that there will be noeligibilty to the Guaranty Fund
Date
3.4 Homeowner Exemption - One &'Two Family Only
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
109A.1 Licensing of Construction Supervisors Except for those structures governed by Construction Control in Section 116.0, effective July I. 1982, no individual
shall be engaged in directly supervising persons engaged in construction, reconstruction, alteration• repair, removal or demolition involving the structural elements of
buildings or structures, unless he or she is licensed in accordance with the rules and regulations promulgated by the BBRS entitled Rules and Regulations for Licensing
Construction Supervisors:
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section: provides that if a
Homeowner engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For 1 tie purposes of this section only, a Homeowner is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, oil
which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs
more than one home in a two-year period shall not be considered a Homeowner.
I f you are applying under this section si n below:
Signature
our stgnatur canes certain responsibilities, including but not necessarily limited to, general liability
RESIDENTIAL 2002
0
NOTICE TO LICENSED CONTRACTORS: The Building Code provides in the Rules and Regulations section that any licensed Construction
Supervisor. whether or not they have taken the permit are responsible for icode 'compliance. (see Appendix of 780 CMR R5.2).'15)
SECTION, d - WORKER'S COMPENSATION INSURANCE AFFIDAVIT (MGL C 152 § 25)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure toprpvide this affidavit
will result in the denial of the issuance of the building permit: - Signed Affidavit Attached: ❑ yes ❑ rho
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
❑ new construction* ❑ addition ❑ alteration ❑ repairs ❑ chimney/ p woodstove
(encrg
,�v report required) (energy report required) fireplace
❑ deck ❑ pool ❑ accessory bldg. ❑ replacement window/door ❑ other ❑ demolition
(shed, -`garage) no. of windows_ doors_ (specify below): (specify below):
If new construction. please complete the following:
Single Family: no. of bedrooms no. of baths`
Two Family: no. of bedrooms unit I no. of baths unit l'
no. of bedrooms unit ? no. of baths unit
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil. electricity, other (specify):'
❑ Boiler (heating) - fuel gas (naturalorpropane), fuel oil, electricity, other (specify): '
❑ HVAC (combined unit) - primary fuel. natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil Other'
Brief Description of Proposed Work:
' E E WRI
SECTION - 6 ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (S) to be completed by permit applicant
1: BuildIHQ
2. Electrical
Phinibing
4. Mechanical (H%'AC)
s. Total = 0 - ? — 3' - 4)
* Estimated Total s 5006,, Ob
SECTION 7A - OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies for building permit)
(please print)
L as Owner of the subject property hereby authorize
to ac my behalf. T al natr re tiye to work authorized by this building Permit application.
ld
t
Signature I ONvner Date
SECTION 7B - OWNER/AUTHORIZED AGENT DECLARATION
L as Owner/Authorized Agent hereby' declare that the statements,,and information
on the foregoing pplication are true and accurate; to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Sianatur of Owner/Authorized Agent Dsate
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r_ E SECTION - INSl' CTOR'S' REVIEW/COMMENTS. .
1. Date plan reviewed: /
2. 30 days to review period expires:
3. OK to issue date: -
4. OK to issue subject to requested submittals(see project review worksheet):
Date:
5, DENIED (see project review worksheet):
Date:
6. HOLD reason:
Date:
e n Board of Appeal ct'
7. HOLD subject to o g pp on.
Comments:
:
Date.
8.
,
9. Inspector's Signature:
Date:
SECTION 9 - APPLIC OTIFICATION
Applicant inform f a ov Date: -' '� f Time: / Clerk:
pl? f
'
Comments:
-04
6 s s
SECT = ION 10 FICE\INSPECTOR S NOTES
—7Less
Total Permit Fee: $
Application Fee: $25.00
Remaining C� Balance. $
E• Gross Area - N
TOTAL FEE: r New Construction total sq. ft.
Gross Area - Alteration total sq. ft.
Aw/may`
Peranit sued To..
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-SECTION 11 ADDITIONAL COMMENTS/S T S
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13 FOUNDATION ONLY
$25.00 APPLICATION FEE IS NON-REFUNDABLE do NON-TRANSFE RA13LE '
DATE RECFiEIVED
DARTMOUTH BUILDING DEPARTMENT
N
400 Slocum Road, P.O. Box 79399
Dartmouth, MA 02747
z ,
`.:••�fifi°- `'' 508-910-1820 FAX 508-910-1838
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE
u .. ,.
+i '. _$
-.p':.Z ..Ss .=•. +K �.'Y`F� .Y 5r^
RECEIVED BY. t
BUILDING PERMIT u�r
DATE SENT FOR REVIEW.
OK TO ISSUE -SIGNATURE:
.. Buil mg Commiss' ner/Inspector o Buildings
AP
"C utsieFlooZoro sd se BAZonn District: urZ>p
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED
❑ Board ❑Board ❑Con Com ❑Demo❑ Elec�<®.Energy
of _ of DPW[] Report
Appeals Health Affidavit Card Seut Gu.OiE ollow up* "ate
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P JT
,....f ''x�; #'.T �'K ✓t'°: a`. � d � k. .:�X5 t�,�,yK.,, `.._ �. .e`_-s^�-,.i 3 c' S.S.
.. � .,�'�:. ,t 4mt, ..*.._e�X.,� Y k :,"-�'�"``•u.,'...E
❑ Fire. ❑Gas [7Plannbig Board ❑ Sewer Card Water Card �: ❑ Zomng Other'
,.13 .�
Chief toff �
C Cu �� /.Cut Off"` /;Cut Off
.Review*
- "'
., o� .�.it"`^
IM UIRES INSPECTOR S REVI BEF RETHE ISS E OF A PERMIT
Q EW O UANC
zrDii EPARTMENTAL APPROVAL
Zoning Review: L11 Signature: Date:
Energy Report: Sig-.iature:IV Date:_
Fire Chief: Signature: Date:
Board of Health: Signature:7�W Date:
Conservation Commission: Signature: Date:
Other:r�d Signatu Date:
Description of work being p r orme
SECTION 1 SITE INFORMATION r°-RMx
NUMBER OF PLANS SUBMITTED:
SITE PLAN SUBMITTED. ❑ yes f❑ no
t � ��(� ��1'i�-i,��
1.2 Assessors Plat Lot Number:
1.1 Property Address: y�
Plat 6 Lot _ — -' M
Nearest Cross Street:
°
1.3 Historical District ❑ yes ❑ no
Subdivision Name: DARIM ULA
Has application been submitted to the historic Commission?
Total Land Area Sq. Ft.: � .� �,,�
� �, �
0 yes ❑ no Date:
1.4 Water Supply (MGL c 40 § 54):
1.5 Sewage Disposal System:
❑ Municipal❑ Private Well
❑ Municipal ❑ On fite iDsposa 1 System
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